Letters

Storm over screening for prostate specific antigen

BMJ 2002; 324 doi: http://dx.doi.org/10.1136/bmj.324.7350.1392 (Published 08 June 2002) Cite this as: BMJ 2002;324:1392

Right to choose is important

  1. Martin J Duckworth, consulting engineer (martin.duckworth{at}btopenworld.com)
  1. 29 Freemans Close, Leamington Spa, CV32 6EZ
  2. Prostate Cancer Awareness Net, 16240 San Pedro, No 123, San Antonio, TX 78232-3004, USA (http://www.pcaawareness.net/)
  3. 1120 North Charles Street, Baltimore, MD 21201, USA
  4. British Columbia Cancer Agency, Vancouver, BC, Canada V5Z 4E6
  5. Bristol

    EDITOR—Yamey and Wilkes argue that questioning cancer screening, specifically prostate specific antigen (PSA) screening can be a risky business in America.1 My prostate cancer, like so many others, was silent and only revealed after a PSA test that my daughter nagged me into adding to my biennial company medical examination—unfortunately too late to guarantee a cure. After surgery and adjuvant radiotherapy I probably have a better prognosis than two colleagues who presented with bone metastases (and PSA values, when tested, in the 100s).

    My PSA result alerted me to a potential problem and let me enter an informed debate with the medical profession—no one forced me to have a biopsy, or an operation, or opt for surgery over radiotherapy, or decline hormone therapy, or do nothing. I could talk to my doctors, read books, and use the internet. I could assess the risks and benefits of a radical prostatectomy and, what is more, carry out this assessment against the background of a medical profession uncertain as to the best course of treatment for someone presenting with my results.

    The key issue is that I could participate in making a life threatening personal decision, rather than have participation (and, by extension, timely treatment) denied to me because PSA screening had been ruled out for the entire male population on the basis of historical statistics. I am enough of a cynic to believe that some of the uncertainty surrounding PSA testing policy in the United Kingdom relates to resources.

    During my decision making process, I came across a paper on dilemmas in treating early prostate cancer.2 It was easy to work out that there just aren't enough experienced urologists (who are dextrous enough to carry out this tricky operation successfully and have the courage to attempt it) to carry out the number of radical prostatectomies that early detection by PSA testing would indicate. This sample of 244 urologists had a mean of 14.1 years' experience (range 2-30 years), and 130 of them managed 100 patients or more with prostate cancer. Expertise in performing radical prostatectomy was restricted to comparatively few—98 reported having ever performed the procedure and only 12 (14%) that they performed 20 or more operations yearly.

    I also suspect that the United Kingdom is far short of the number of three dimensional conformal radiotherapy machines needed to offer that treatment option.

    References

    1. 1.
    2. 2.

    Innuendo in article is insulting

    1. Rick Ward, founder. (ricklward{at}pcaawareness.net)
    1. 29 Freemans Close, Leamington Spa, CV32 6EZ
    2. Prostate Cancer Awareness Net, 16240 San Pedro, No 123, San Antonio, TX 78232-3004, USA (http://www.pcaawareness.net/)
    3. 1120 North Charles Street, Baltimore, MD 21201, USA
    4. British Columbia Cancer Agency, Vancouver, BC, Canada V5Z 4E6
    5. Bristol

      EDITOR—Yamey and Wilkes offer tabloid journalism to advance their position by saying that they dared to tread on the toes of a powerful pro-screening lobby.1 They point out that this lobby has major competing interests, since it has a financial stake in offering investigations and treatments for prostate cancer. Even some of the charity groups in this lobby have competing interests, since they receive funding from manufacturers of treatments for prostate cancer or have ties with the American Urological Association. The backlash against their piece, they say, smells like a battle to hold on to power and money.

      I am a survivor of prostate cancer caught by screening, and I am insulted by the implication that we survivors who object to their distortion of evidence on screening for prostate cancer are part of a dark conspiracy, a “lobby” orchestrated by powerful self serving interests. We survivors want only one thing: that no man be “blind sided” by prostate cancer because of ignorance of the potential and thus no opportunity to exercise the right to decide for himself. Nobody tells us what to say, nor what we want.

      In September 1994 I was “caught” by screening during the annual prostate cancer awareness week, with prostate specific antigen (PSA) of 14 ng/ml at the age of 57. This prompted the urology consultation that found an irregular prostate gland by digital rectal examination, and the resulting ultrasound guided biopsy found four cores out of seven cancerous. In December 1994 another asymptomatic man, because of my experience with screening, received a diagnosis at age 64, PSA 4+, but a more aggressive cancer on biopsy (Gleason 4+3). He chose not to intervene. In September 1997 his PSA was 10, in December 1997, 90. He was buried in the summer of 1998, his last months in a morphine induced stupor.

      My intervention, on the other hand, was state of the art for the time, a combination of hormonal ablation, external radiation, and implanted radiation. My PSA on 16 July 2001 was 0.11 ng/ml.

      My quality of life is compromised only by mild urinary urgency and increased frequency, and a slightly less than average sexual capability for a man of 64. Small inconveniences compared with dying. Pain associated with screening? Discomfort more accurately describes the process itself. Psychological trauma? Compared with dying, minimal.

      Mortality from prostate cancer declined over 18% from 1993 to 1998. Screening works. But, more importantly, men do not need protective paternalistic doctors interfering with their health decisions by presenting distortions of studies and research as anti-screening fact.

      References

      1. 1.

      Give men facts on prostate cancer

      1. E Darracott Vaughan, president, American Urological Association (wisett{at}auanet.org),
      2. David G McLeod, president, American Foundation for Urologic Disease
      1. 29 Freemans Close, Leamington Spa, CV32 6EZ
      2. Prostate Cancer Awareness Net, 16240 San Pedro, No 123, San Antonio, TX 78232-3004, USA (http://www.pcaawareness.net/)
      3. 1120 North Charles Street, Baltimore, MD 21201, USA
      4. British Columbia Cancer Agency, Vancouver, BC, Canada V5Z 4E6
      5. Bristol

        EDITOR—The American Urological Association and the American Foundation for Urologic Disease are aware of the controversy surrounding the use of prostate specific antigen (PSA) testing. 1 2 We have followed the debate in the San Francisco Chronicle since it printed the article by Yamey and Wilkes. Our previous letter was not printed by the Chronicle.

        Both organisations support informed patient decision making in the early detection of prostate cancer. Along with the American Cancer Society, the National Comprehensive Cancer Network, and other groups, we believe that men over age 50 should consider the test—but should also discuss the benefits and limitations with their doctors. Men at higher risk, such as African-American men and men with a family history of prostate cancer, should consider the test more seriously. All men should know that prostate cancer is the second-highest cause of cancer deaths in American men. As non-profit organisations we promote the highest standards of urological clinical care through research, education, formulation of health policy, and patient outreach.

        In 2000 compelling data showed a decrease in prostate cancer mortality in white men less than 85 years of age to rates below those existing in 1986 in the United States.3 Interestingly, 1986 was the year that PSA testing was approved. Another recent report shows that a downward trend has emerged in mortality from prostate cancer that coincides with an increase in PSA screening, particularly in the United States and Canada.2 These data fuel the support for widespread PSA testing in conjunction with informed patient decision making. Our organisations recognise that more research is needed to improve and refine prostate cancer detection and strongly advocate for more research funding to combat and prevent this devastating disease.

        The American Urological Association and the American Foundation for Urologic Disease respect the right to express opinion and do not wish to silence Yamey and Wilkes. Since the American Urological Association's formation in 1902, we have seen a century of medical achievements, a field fraught with controversy, and novel, unpopular ideas spurring advances that gave doctors new ways to diagnose and treat disease. We all share a responsibility to ensure that the patient comes first. Today's patient seeks to be well educated and informed, and promoting distrust of cancer detection techniques does more harm than good. We seek ways to improve prostate cancer detection, outcomes, and quality of life for patients—by developing new testing tools or refining our current ones, not disparaging them. American men do not need yet another excuse to ignore their health.

        References

        1. 1.
        2. 2.
        3. 3.

        Number needed to test needs to be known

        1. Mario L de Lemos, provincial drug information coordinator. (mdelemos{at}bccancer.bc.ca)
        1. 29 Freemans Close, Leamington Spa, CV32 6EZ
        2. Prostate Cancer Awareness Net, 16240 San Pedro, No 123, San Antonio, TX 78232-3004, USA (http://www.pcaawareness.net/)
        3. 1120 North Charles Street, Baltimore, MD 21201, USA
        4. British Columbia Cancer Agency, Vancouver, BC, Canada V5Z 4E6
        5. Bristol

          EDITOR—The debates on screening for prostate specific antigen (PSA) inspired by the article by Yamey and Wilkes make no mention of how many men need to be tested to identify one prostate cancer or prevent one related death.1 I believe that an agreed estimated number (or range of numbers) needed to test should be the first step to address this controversy.

          For every 1000 men age 55-74 who have initial PSA screening and digital rectal examination, 189 would have PSA >4 ng/ml and 27 of these would have biopsy proved prostate cancer. 2 3 If we exclude patients with minimal disease who require no treatment and those with incurable advanced disease, this leaves 14 patients (50%) with potentially curable, localised disease.w1-w3 About 10 of these patients (70%) would be cured with prostatectomy or radiation, assuming cure as being alive and free of disease 10 years after treatment.w4-w10

          In other words, PSA screening could prevent 10 deaths related to prostate cancer per 1000 men tested, or a number needed to test of 100. Whether this number is too high or too low depends on many other factors, such as the risks associated with PSA testing. I suspect, however, that many involved in this debate have very different numbers needed to test in mind, hence their apparently irreconcilable differences.

          Footnotes

          • Embedded Image 10 more references are available on bmj.com

          References

          1. 1.
          2. 2.
          3. 3.

          Summary of responses

          1. Alison Tonks, freelance medical editor.
          1. 29 Freemans Close, Leamington Spa, CV32 6EZ
          2. Prostate Cancer Awareness Net, 16240 San Pedro, No 123, San Antonio, TX 78232-3004, USA (http://www.pcaawareness.net/)
          3. 1120 North Charles Street, Baltimore, MD 21201, USA
          4. British Columbia Cancer Agency, Vancouver, BC, Canada V5Z 4E6
          5. Bristol

            EDITOR—The BMJ received 34 letters from 31 people responding to three articles discussing screening for prostate cancer and a debate on bmj.com14 Responses included 11 from patients with prostate cancer, or their relatives, another 11 from doctors and other healthcare professionals, and five from patients' groups (including three from the same author).

            Seven respondents supported Yamey and Wilkes's views; one even described them as courageous. Seventeen respondents opposed them. The rest were neutral. Only two responses came from urologists or their professional bodies. One of these was from Germany, the other from the American Urological Association and the American Foundation for Urologic Disease. Both supported screening with fully informed consent.

            This correspondence illustrates clearly the gulf between men's experience of screening for prostate cancer (those that wrote in were overwhelmingly positive), and the evidence from research (decidedly unclear). In these letters, the gulf is filled with anecdote, opinion, dogma, and mud slinging. Only four respondents cited any research to substantiate their arguments.

            Six letters commented on the high temperature of the screening debate, five blaming Yamey and Wilkes for their inflammatory style. It was, they said, tabloid, paternalistic, demonising, unbalanced, and distorted. The sixth, from Anne Peticolas, a systems programmer from Austin, Texas, blamed the emotional impact of the word cancer. “If strong emotions evoked by the word cancer were not involved, men considering an exactly similar condition might [at least] be able to comprehend, as many obviously cannot, how a rational person could think screening inadvisable,” she wrote. A general practitioner from London, Malcolm Grant, commented that all this emotion seems odd to Europeans, who accept that caution is required until better evidence is available.

            A third of the responses were from people with personal experiences of prostate cancer. They were well informed consumers who acknowledged professional uncertainty about screening. All but one of them supported it. Many described themselves as “survivors” and felt lucky to be alive after ad hoc screening picked up their cancer. The common theme was that men should be able to make up their own minds about screening, and be screened without prejudice if they wanted it. All that men need from doctors is accurate, up to date information, not paternalistic interference with their legitimate right to health awareness. Only one of these 11 letters criticised the screening test for prostate specific antigen (PSA). Geraint Lewis, an anaesthetist from Ottawa, wrote that his father nearly died after the prostatic biopsy that followed a positive PSA test. The biopsy result was negative.

            Some respondents saw an attack on screening for prostate cancer as an attack on men, or at least a further setback in the campaign to encourage reluctant men to take better care of themselves. Others felt the debate on screening for prostate cancer is just a small part of the wider, and entirely political, debate on screening in general.

            Finally, two people wrote in to celebrate a US culture of free speech that allows such a loud and vigorous public response to a published article. “Freedom of speech [in the United States] remains alive and well,” wrote Ron Davis, director of the Center for Health Promotion and Disease Prevention in Detroit. “It is precisely that freedom that permits people to attack Yamey and Wilkes and call for their dismissal. If their employers fire them, however, or attempt to control what they write, then and only then should we worry.”

            References

            1. 1.
            2. 2.
            3. 3.
            4. 4.